Provider Demographics
NPI:1811292501
Name:GROGAN, MARK LESLIE
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:LESLIE
Last Name:GROGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BAPTIST DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-2009
Mailing Address - Country:US
Mailing Address - Phone:601-607-7204
Mailing Address - Fax:601-607-7430
Practice Address - Street 1:401 BAPTIST DR
Practice Address - Street 2:SUITE 306
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2009
Practice Address - Country:US
Practice Address - Phone:601-607-7204
Practice Address - Fax:601-607-7430
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4334225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640881013OtherTAX ID
MS0220392Medicaid